Tuesday, July 30, 2013

The misery of low back pain often drives people to the doctor to seek relief. But doctors are doing a pretty miserable job of treating back pain, a study finds.

Physicians are increasingly prescribing expensive scans, narcotic painkillers and other treatments that don't help in most cases, and can make things a lot worse. Since 1 in 10 of all primary care visits are for low back pain, this is no small matter.

What does help? Some ibuprofen or other over-the-counter painkiller, and maybe some physical therapy. That's the evidence-based protocol. With that regimen, most people's back pain goes away within three months.

But when researchers at Beth Israel Deaconess Medical Center in Boston looked at records of 23,918 doctor visits for simple back pain between 1999 and 2010, they found that doctors have actually been getting worse at prescribing scientifically based treatments.

Doctors were recommending NSAID pain relievers and acetaminophen less often. Instead, they were increasingly prescribing prescription opioids like OxyContin, with use rising from 19 percent of cases to 29 percent. Over-the-counter painkiller use declined from 37 percent to 25 percent. Other studies have found that opioids help only slightly with acute back pain and are worthless for treating chronic back pain.

"That's a big public health issue," says Dr. John Mafi, chief medical resident and a fellow at Beth Israel Deaconess. Mafi was the lead author of the study, which was published online inJAMA Internal Medicine. In the 1990s doctors were criticized for ignoring patients' pain, Mafi says. Some of that criticism was valid, but doctors have overreacted. "What magic bullet better than a very powerful pain medication?"

About 43 percent of patients taking opioids for chronic back pain also had other substance abuse disorders, the researchers found. In 2008, almost 15,000 people died from overdoses of prescription opioids, and abuse has surged among women. Opioids may be necessary in some cases, Mafi says, but "they're certainly not first-line."

Doctors were also quick to whip out the prescription pad and call for CT and MRI scans for people with lower back pain, the study found. The number of people getting scans rose from 7 to 11 percent. Though those scans won't hurt the patient, in most cases they don't find anything wrong. And they are expensive, costing $1,000 or more.

Patients are partly to blame for the rush to scan, Mafi says. "Patients are expecting very comprehensive evaluations," he tells Shots. "There's a sentiment perhaps if my doctor ordered an MRI for my back pain they really listened to me. It's almost validating."

And in an era when doctors are rated online by patients, "doctors have an incentive to make patients happy," Mafi says.

Financial incentives for doctors may also be a factor. This study didn't examine why doctors aren't following clinical guidelines for treating back pain, but other studies have found that when doctors own imaging equipment, they are more likely to use it.

Doctors should be cut a little slack, a journal commentary accompanying this study says, because guidelines have been conflicted on back pain treatment until recently, and it takes 17 years, on average, for new treatment standards to be widely adopted. But creating checklist-type guidelines for doctors would help speed that process, the commentary says. So would requiring patients to pay more of the cost of expensive imaging, and providing payment incentives for doctors who do the right thing.

"For the majority of new-onset back pain [cases], it gets better within three months," Mafi says. "Unfortunately, we don't have fancy treatments that cure it." Time, some ibuprofen and gentle exercise aren't sexy. But they most often do the trick.

Friday, July 19, 2013

A few months after being diagnosed with multiple sclerosis (MS) at age 17, Jon Hood of Phoenix, AZ, wandered through his home gathering medications—in an attempt to kill himself to escape the physical pain he was experiencing as a result of the disease. He swallowed a pile of pills with a glass of water. Hours later, he woke up disoriented, confused, and suffering from severe stomach cramps. "My mom heard me vomiting and took me to the hospital," says Hood.

He had begun feeling pain in his limbs at age 11. At 13, leg cramps kept him up all night. By 17, Hood had lost his vision, developed a limp, and could no longer play sports.

He went to a string of doctors, but none were able to pinpoint the cause of his symptoms. Many thought he was making them up. Although physical pain is becoming increasingly recognized as a symptom of MS, many people—including doctors—are unaware that it can be caused by the disease. Some research suggests that more than half of MS patients experience pain at some point during the course of the disease, and that nearly half experience chronic pain. MS has been associated with trigeminal (facial) pain, painful spasms, burning or shooting pain, and back pain.

Hood was finally diagnosed with MS following a series of imaging exams and lab tests that spanned a few weeks.

"The day I attempted suicide, I was with a group of friends at a gas station. I offered to run in and get some sodas. My friend said, 'Stay here; I'll run in real quick,'" says Hood, now 24. "I suddenly felt like I would always be treated differently." The statement reinforced his sense of hopelessness at the hands of an incurable and painful disease.

Hood's despair isn't unique. Reports show that 50 percent of chronic pain patients consider suicide to escape the unrelenting agony of their pain. A study published in Psychosomatic Medicine in 2006 found that relative to the general population, risk of death by suicide appears to be at least doubled in chronic pain patients.

Despite these sobering statistics, there's reason for hope. Beyond the bevy of pharmaceutical options available to target pain and accompanying depression, a variety of self-help tools are available. First, however, the cause of the pain must be identified by a neurologist, as different pain conditions require different treatments.

Thursday, July 11, 2013

Researchers using functional magnetic resonance imaging (fMRI) to define neural signatures of pain in the brain face a daunting task, because pain elicits complex and distributed activity in many of the same brain regions as other intense sensations. Now, Giandomenico Iannetti, University College London, UK, and colleagues have identified fine-grained differences in brain activity, scattered across multiple primary sensory regions, that distinguish pain compared to the response to other strong sensory stimuli such as loud noise and bright light.

"There is something specific" in brain activity during pain compared to other sensations, said Iannetti. "But that something is very, very tiny."

Iannetti's group found the pain-specific patterns in some unlikely places: Even the visual and auditory cortices—regions thought to be dedicated to sight and hearing, respectively—showed pain signatures. That means that processing of pain and other sensory input may be much more widely distributed than previously appreciated. "It's not just the commonly thought brain areas that are representing the senses," said first author Meng Liang.

The results support the idea that, in the quest to understand the brain in pain, researchers cannot confine themselves to looking at bulk changes in brain activity in broad areas typically associated with pain, but will need to look for more discrete, spatially defined signals all over the brain.

The study appeared June 11 in Nature Communications.

Painful stimuli evoke activity in regions of the brain involved in sensory processing as well as other functions such as attention, emotion, and consciousness—areas collectively known as the "pain matrix." In the last several years, researchers have begun to use sophisticated, multivariate pattern analysis techniques to identify complex patterns of activity in these regions that correlate with pain (see PRF related news story).

But Iannetti and others have argued that much of the activity ascribed to pain is not specific, but instead reflects a more general brain response to any attention-grabbing, highly salient sensory stimulus (for a review, see Legrain et al., 2011). In a study published last year, his group identified an electroencephalographic (EEG) response in the primary somatosensory cortex (namely, gamma band oscillations) that is more closely correlated with the intensity of pain, independent of salience (Zhang et al., 2012). In their new study, they pushed on to see if they could identify fMRI signals that defined the quality of a highly salient stimulus—for example, pain versus a loud noise.

To do that, the team analyzed fMRI data from an earlier experiment in which they recorded blood oxygen level-dependent (BOLD) signal changes in the primary somatosensory, visual, and auditory cortices after four isolated, intense stimuli: painful heat, non-painful touch, bright light, and loud noise. The fMRI signal was parceled into volumetric pixels (voxels) 3x3x3 mm in size. Using the traditional method of voxel-by-voxel analysis, the researchers previously found that brain responses to the different sensations were almost indistinguishable (Mouraux et al., 2011). This time they used multivariate pattern analysis to search for subtle changes in the spatial pattern of activity across voxels.

In the experiment, 14 healthy young adults underwent four testing runs; in each, they received 32 stimuli (eight of each modality), followed by a brain scan a few seconds after each stimulus. The researchers used the data from the first three runs to train an algorithm to identify spatial patterns of neural activity that correlated with stimulus modality in each subject. Then they tested whether the algorithm could recognize the kind of stimulus applied in the fourth run.

The algorithm consistently achieved above-chance accuracy. For example, patterns of activity changes in the primary somatosensory cortex (S1) distinguished pain from touch, with 63 percent accuracy on average. That success made sense, since S1 is known to be involved in both pain and touch sensation. But, to the researchers' surprise, even the visual and auditory cortices (V1 and A1) showed activity patterns that were different for pain compared to touch, and activity in either region distinguished between the two stimuli with 59 percent accuracy.

The team used two strategies to ensure that the patterns reflected stimulus modality, not just strength—that is, that the visual cortex was not registering pain simply because the painful stimulus evoked an especially large overall brain response. During testing, the investigators asked subjects to rate the salience of each stimulus and then tuned the intensity for each subject so that each stimulus was equally salient. And, in the data analysis, they normalized responses in each cortical region to the mean response amplitude in that region to subtract out overall differences in response magnitude.

The predictive brain activity that emerged from the analysis was scattered around each sensory region. For example, in V1, activity in a diffuse sprinkling of voxels predicted whether a stimulus was pain versus touch, whereas a distinct collection of voxels distinguished pain from sound—indicating that different sensations elicit activity in different neurons, even within non-corresponding sensory cortices.

Pain signatures are subtle and scattered: The voxels that most strongly distinguished between stimuli are sprinkled around all three primary sensory cortices tested, and differ by stimulus. In the somatosensory cortex (S1), for example, the activity in some voxels distinguished pain from touch (top row, first box), while others distinguished pain from sound (second box). Credit: Liang et al., 2013, Nature Communications, distributed under a Creative Commons license.

Now, the Iannetti group is trying to determine just how much information about a sensation, such as its intensity and frequency, is encoded in the different sensory cortices. Already, in the current paper, they report that activity in non-corresponding sensory cortices weakly predicts one additional piece of information: stimulus location. Activity patterns in the auditory cortex, for example, discriminated with above-chance accuracy (53 percent) whether a touch stimulus occurred on the second or fifth finger.

The discovery that sensations elicit specific activity in seemingly irrelevant cortical regions was a surprise to the group. "We couldn't even imagine that could be possible," Iannetti said. The results, he said, are "evidence that the dogma that the primary sensory cortices are only able to respond to stimuli of their own modality is not correct." Instead, it appears that "primary sensory cortices are deeply multimodal."

The questions remain of why activity in the visual and auditory cortices correlates with pain, and whether those regions actually help to produce the sensation of pain. "With these multivariate pattern analyses, there are lots of signals we can pick up on, and some of them are causally related to the percepts, and others are not," said Tor Wager, University of Colorado, Boulder, US, who was not involved in the study. One possible explanation for pain-associated patterns in the visual cortex, he said, is that "there's a withdrawal of attention from the visual world when you're experiencing pain."

Looking aheadRecently, Wager and colleagues used a similar multivariate pattern analysis technique to elucidate a signature pattern of activity, in the pain matrix and other regions, that marked the response to painful heat in healthy subjects. That activity pattern discriminated between pain and other kinds of salient events, such as viewing emotionally evocative pictures (see PRF related news story).

Wager said the Iannetti group's paper is another example of how sophisticated analysis techniques can successfully tease out stimulus-specific patterns. And results such as these make Wager hopeful that the field will be able to identify signature patterns of brain activity for pain and other sensations that will be useful as biomarkers or diagnostic tools.

Iannetti is less optimistic. "A key point is that we do this within subjects," he said. In Wager's recent study, a specific brain activity pattern registered pain intensity and discriminated between pain and some other salient events across subjects. But Iannetti and Liang said that distinguishing the sensory modality (e.g., pain vs. sound) across subjects may be another matter. "The features allowing us to classify what the stimulus was are so small, and so discreet, and so scattered, that I would be very surprised if that works when comparing different brains," Iannetti said. He said he and Liang are now testing that idea.

Wednesday, July 03, 2013

Chronic pain in children and teenagers is a dramatically growing problem, with hospital admissions for youngsters with the condition rising ninefold between 2004 and 2010, a new study suggests.

The most common type ofchronic pain among kids in the study was abdominal pain, which was reported in 23 percent of cases, according to the study.

Other conditions included reflex sympathetic dystrophy syndrome, characterized by nerve pain in the limbs, which affected 9.2 percent of children in the study, and chronic pain syndrome, which occurs when pain lasts longer than three months (6.4 percent). Children also reported headaches and migraines, limb pain and back pain.

"We are seeing a lot more young patients with chronic pain syndrome," said study author Dr. Thomas A. Coffelt, assistant professor of clinical medicine and pediatrics at the Indiana University School of Medicine in Indianapolis. "It is quite alarming to us."

For the study, researchrs gathered information on 3,752 children admitted to 43 pediatric hospitals throughout the United States.

The typical chronic pain patients were white and female, with an average age of 14. The average hospital stay was 7.32 days, according to the study.

The vast majority of the patients in the study received additional diagnoses while in the hospital, with an average of 10 diagnoses per child. Children were diagnosed with conditions such as abdominal pain, mood disorders, constipation and nausea. Altogether, 65 percent of patients received a gastrointestinal diagnosis, and 44 percent received a psychiatric diagnosis.

The results also showed that even after being hospitalized, many youngsters continued to have pain. Coffelt said that 12.5 percent of the children were back in the hospital within a year — 9.9 percent were readmitted at least once, and 2.6 percent more than once.

Why so many children have chronic pain is the "million-dollar question," Coffelt said. Depression, anxiety and other mood disorders, which were secondary diagnoses in many youngsters, may play a role, he added.

Another possible cause could be physical, emotional and sexual abuse or assault, though these were associated with just 2.1 percent of young pain sufferers.

"We can't identify the underlying [cause] of pain, which is why we struggle with it," Coffelt said. "We need to find a better way to treat these patients."

"Chronic pain is quite common in pediatrics," said Gary A. Walco, director of pain medicine at Seattle Children's Hospital, who was not involved in the study.

"The chronic pain field now recognizes that a good deal of chronic pain has to do with a change in how the brain and spinal cord are processing the stimuli coming into the body," Walco said. "This study shines a light on how poorly understood and mismanaged recurrent and chronic pain syndromes are."

However, Walco also said he believes the number of pain patients reported in the new study is "potentially artificially inflated" due to the diagnostic codes used to identify pain patients. Those codes, Walco said, "leaned in the direction of psychological issues."

The multiple diagnostic procedures and readmissions cited in the study underscore the need to do better when it comes to dealing with pain in youngsters, Walco said. Instead of treating chronic pain as an acute problem, physicians need to focus on rehabilitation, he explained.

And "rather than continuing to see pain as a symptom of another illness, parents need to recognize pain is the illness, and seek out a pain expert for treatment," Walco said.

Tuesday, July 02, 2013

PORTSMOUTH, Ohio — Prescription pain pill addiction was originally seen as a man's problem, a national epidemic that began among workers doing backbreaking labor in the coal mines and factories of Appalachia. But a new analysis of federal data has found that deaths in recent years have been rising far faster among women, quintupling since 1999.

More women now die of overdoses from pain pills like OxyContin than from cervical cancer or homicide. And though more men are dying, women are catching up, according to the analysis by the Centers for Disease Control and Prevention. And the problem is hitting white women harder than black women, and older women harder than younger ones.

In this Ohio River town on the edge of Appalachia, women blamed the changing nature of American society. The rise of the single-parent household has thrust immense responsibility on women, who are not only mothers, but also, in many cases, primary breadwinners. Some who described feeling overwhelmed by their responsibilities said they craved the numbness that drugs bring. Others said highs made them feel pretty, strong and productive, a welcome respite from the chaos of their lives.

"I thought I was supermom," said Crystal D. Steele, 42, a recovering addict who said she began to take medicine for back pain she developed working at Kentucky Fried Chicken. "I took one kid to football, the other to baseball. I went to work. I washed the car. I cleaned the house. I didn't even know I had a problem."

Ms. Steele, now a patient at the Counseling Center, a rehabilitation center here, remembers getting calls about deaths of high school classmates while working at an answering service for a local funeral home. She counted about 50 women she had known who had drug-related deaths. She believes that had it not been for a 40-day stint in jail for stealing pain pills, she would have been among them.

"I felt like I sold my soul somewhere along the way," said Ms. Steele, whose father was an alcoholic and abusive. "I didn't feel like I deserved to be given a second chance. I thought my kids would be better off without me."

For years, drug overdose deaths in the United States were seen as mostly an urban problem that hit blacks hardest. But opioid abuse, which exploded in the 1990s and 2000s and included drugs like OxyContin, Vicodin and Percocet, has been worst among whites, often in rural places. The C.D.C. analysis found that the overdose death rate for blacks in 2010, the most recent year for which there was final data, was less than half the rate for whites. Asians and Hispanics had the lowest rates.

According to the report, 6,631 women died of opioid overdoses in 2010, compared with 10,020 men.

While younger women in their 20s and 30s tend to have the highest rates of opioid abuse, the overdose death rate was highest among women ages 45 to 54, a finding that surprised clinicians. The range indicates that at least some portion of the drugs may have been prescribed appropriately for pain, Dr. Nora Volkow, director of the National Institute on Drug Abuse, said in an interview. If death rates were driven purely by abuse, then one would expect the death rates to be highest among younger women who are the biggest abusers.

Deaths among women have been rising for some time, but Dr. Thomas R. Frieden, the C.D.C. director, said the problem had gone virtually unrecognized. The study offered several theories for the increase. Women are more likely than men to be prescribed pain drugs, to use them chronically, and to get prescriptions for higher doses.

The study's authors hypothesized that it might be because the most common forms of chronic pain, like fibromyalgia, are more common in women. A woman typically also has less body mass than a man, making it easier to overdose.

Women are also more likely to be given prescriptions of psychotherapeutic drugs, like antidepressants and antianxiety medications, Dr. Volkow said. That is significant because people who overdose are much more likely to have been taking a combination of those drugs and pain medication.

Broader social trends, like unemployment, an increase in single-parent families, and their associated stressors, might have also contributed to the increase in abuse, but they are slow moving and unlikely to be a direct explanation, Dr. Volkow said.

Stella Collins, who runs group therapy sessions at the Counseling Center, said her patients, most of whom are poor, feel trapped. They are squeezing a living out of tiny paychecks. Many get no financial support from the fathers of their children and come from families where alcohol or drugs were abused. Their feelings of inadequacy and shame over not properly caring for their children help drive their addictions, she said.

"Poverty is depression, it's failure, it's sadness, it's low self-esteem," said Ms. Collins. Her mother, an addict, died of a heart attack at age 56 after spending money meant for heart medication on pain pills, she said.

Kathy Newman, 35, who started using pills in her 20s, after her older sister overdosed, and whose oldest son was born addicted, has been drug-free for two years. She now takes classes, and travels around the county telling her story at schools.

For Ms. Steele, the most motivating image is that of her 12-year-old son's face streaked with tears, looking at her through the glass of the prison visiting area. Her eldest son now has custody of him.

"I was at a big stop sign and it was like, 'O.K., which way are you going to go?' " she said.

Portsmouth has worked hard to stop addiction. Easy access to prescription pain pills has been shut down. Mothers of dead addicts give talks at schools. And while Ohio's death rate from overdoses, like the national rate, is still climbing, the rate in Scioto County, where Portsmouth is located, has declined in recent years, according to the city health department.

Ms. Collins works with women in group sessions, teaching them how to like themselves again.

"Watching them die is the hardest part," Ms. Collins said. "You sit in this room and you don't know who's going to make it."